1. MULTISYSTEMIC THERAPY (MST): BASES OF SUCCESS IN TREATING SERIOUS CLINICAL PROBLEMS IN CHILDREN AND ADOLESCENTS
Scott W. Henggeler, Ph.D., Director
Family Services Research Center
Department of Psychiatry and Behavioral Sciences
Medical University of South Carolina
Charleston

2. FAMILY SERVICES RESEARCH CENTER
Scott W. Henggeler, Ph.D., Director
Cynthia Cupit Swenson, Ph.D., Associate Director
Sonja K. Schoenwald, Ph.D.
Phillippe B. Cunningham, Ph.D.
Colleen Halliday-Boykins, Ph.D.
Elizabeth Letourneau, Ph.D.
Jeff Randall, Ph.D.
Melisa D. Rowland, M.D.
Lisa Saldana, Ph.D.
Ashli Sheidow, Ph.D.
Jason Chapman, Ph.D.

3. FSRC MISSION:
To develop, validate, and study the dissemination of clinically effective and cost effective mental health and substance abuse services for youths presenting serious clinical problems and their families

4. OTHER MST-RELATED ORGANIZATIONS
MST SERVICES (has license with Medical University of South Carolina for transport of MST technology and intellectual property)
Mission: Assists organizations in development of MST programs and builds (or provides) internal capacity of organization to maintain quality assurance system
MST INSTITUTE
Mission: To facilitate the dissemination of evidence-based practices with high treatment fidelity
NETWORK PARTNERS in Ohio, Hawaii, Colorado, Tennessee, Pennsylvania, Connecticut, and Norway

5. Disclosure Statement
Presenter is stockholder in MST Services Inc., which has the exclusive licensing agreement through the Medical University of South Carolina for the transport of MST technology and intellectual property.

6. STRUCTURE OF MST
Treatment targets serious juvenile offenders at high risk for out-of-home placement and their families
MST team includes 3-4 master’s level therapists and a 50% time supervisor
Therapists provide services 24/7
Therapists carry caseloads of 4-6 families each for an average of 4 months
Services are provided in homes and other community settings
MST team is supported by intensive quality assurance system to optimize youth outcomes

7. CRITICAL COMPONENTS OF MST
1. Addresses the known causes of antisocial behavior comprehensively -- at youth, family, peer, school, and community levels
2. Provides intensive treatment where problems occur – in homes, schools, and neighborhoods
3. Views caregivers as central to achieving favorable youth outcomes – family-based
4. Intensive quality assurance system supports MST program fidelity and youth outcomes
5. MST provider organizations are accountable for family engagement and youth outcomes

8. Principles of MST 1. Finding the Fit 2. Positive & Strength Focused
3. Increasing Responsibility
4. Present-focused, Action-oriented & Well-defined
5. Targeting Sequences
6. Developmentally Appropriate
7. Continuous Effort
8. Evaluation and Accountability
9. Generalization

9. MST Analytical Process
Environment of Alignment and Engagement
of Family and Key Participants
Measure
Re-evaluate
Prioritize Do
Intermediary
Goals
Intervention
Development
MST Conceptualization
of “Fit”
Assessment of
Advances & Barriers to
Intervention Effectiveness
Implementation
MST
Analytical
Process
Referral
Behavior
Overarching
Desired Outcomes
of Family and Other
Key Participants
Referral Behavior
Clear behavioral description
(e.g. systems affected, frequency, intensity, duration)
Desired Outcomes of Family and Key Participants
All key participants are identified
Outcomes written from participant’s perspective
Overarching Goals
Connected to referral behavior
Achieve identified outcomes
Guide direction of treatment
Specific enough to establish termination criteria
understandable to an outside observer
MST Conceptualization of “Fit”
Understanding how behavior makes sense - “What’s the Fit?”
Fit Circle: fit factors & evidence - “Where’s the evidence?”
Develop hypotheses & prioritize (this also occurs throughout process)
Intermediary Goals
Contributes to achieving Overarching Goals
Targets most immediate powerful drivers of behavior
Attainable in days or weeks
Simultaneous & sequential steps
Intervention Development - who, what, when and how to make change happen
Consistent with Nine MST Principles
Interventions prioritized
Measurement strategy identified
Intervention Implementation
Empirically validated methods
Builds on strengths
Tests hypotheses
Measures Collected
Assessment of Advances & Barriers
Specific to interventions implemented
Supports or refutes one or more hypotheses
Advances: record steps completed successfully
Barriers: identify specific factors which prevented
successful completion of one or more steps

10. PUBLISHED MST OUTCOMES
10 Randomized Trials and 1 Quasi-Experimental Trial Published (>1000 families participating)
3 with violent and chronic juvenile offenders
1 with substance abusing or dependent juvenile offenders
2 with juvenile offenders
1 with juvenile sexual offenders
2 with youths presenting serious emotional disturbance
1 with maltreating families
1 with adolescents with poorly controlled diabetes
Approximately 10 additional randomized trials are in progress

11. OVERVIEW OF MST OUTCOMES ASSOCIATED WITH:
Criminal Behavior & Violence
Adolescent Substance Abuse
Adolescent Sexual Offending
Mental Health
Child Maltreatment

12. PUBLISHED OUTCOMES FOR CRIMINAL BEHAVIOR
4 Randomized and 1 quasi-experimental trials with serious juvenile offenders
Decreased recidivism (25% to 70%) for as long as 13 years post treatment
Decreased self-reported criminal offending
Decreased out-of-home placement (47% to 64% reductions)
Decreased behavior problems
Improved family relations
Considerable cost savings (Washington State Institute on Public Policy)
1. MST $64,000/youth
15. Bootcamps ($ 7,910)/youth

13. Simpsonville, SC Project

14. Missouri Delinquency Project

15. MST Substance-Related Clinical Outcomes
Serious juvenile offenders: two trials
decreased self-reported substance use
fewer drug-related arrests at 13-year follow-up
Diagnosed substance abusing/dependent juvenile offenders
increased attendance in regular school settings
98% (57 of 58 families) treatment completion (
Incremental costs of MST offset by savings incurred from reductions in days of out-of-home placement at 12 months

16. Long-Term Outcomes for Substance Abusers
4-year treatment effects for violent criminal behavior (.15 versus .57 arrests per year)
higher rates of marijuana abstinence for MST participants at 4-years post treatment (55% versus 28%)

17. MST 12-MONTH OUTCOMES FROM JUVENILE DRUG COURT RANDOMIZED TRIAL (N=161)
Compared with regular drug court, MST had:
fewer positive screens 20% versus 60% (2,000 screens)
less self-reported alcohol and polydrug use
marginally decreased mental health symptoms (CBCL)

18. MST OUTCOMES ASSOCIATED WITH ADOLESCENT SEXUAL OFFENDING
Study with N=16:
3 year rearrest data for sexual offending favoring MST (12.5% versus 75%)
Replication study with N=48:
8-year rearrest data for sexual offending favoring MST (12.5% versus 41.7%)
66% decrease in days incarcerated
Effectiveness study underway in Chicago

19. MST MENTAL HEALTH OUTCOMES-Alternative to Psychiatric Hospitalization Study
Decreased youth externalizing
Improved family functioning
Increased school attendance
At 4 months post referral MST youth had a 72% reduction in days hospitalized and a 49% reduction in days in other out-of-home placements
Higher consumer satisfaction
Positive effects dissipated by 1.5 years
Similar findings in (N=36) replication study in Hawaii

20. MST OUTCOMES ASSOCIATED WITH CHILD MALTREATMENT
Improved parent-child interactions
Current Trial with Child Physical Abuse
Effectiveness Trial (MST versus Group Behavioral Parent Training) with 160 families with an indicated case of physical abuse

21. BASES OF MST SUCCESS
1. Addresses multidetermined nature of serious clinical problems
2. High ecological validity of intensive services
3. Intensive quality assurance (improvement) system
4. Integration of evidence-based intervention models
5. Caregiver viewed as key to long term outcomes
6. Program accountability for family engagement and outcomes

22. 1. MST ADDRESSES MULTIDETERMINED NATURE OF SERIOUS CLINICAL PROBLEMS
Decades of Rigorous Research Show Serious Adolescent Problems Linked with:
Individual adolescent characteristics
Family functioning
Caregiver functioning
Association with deviant peers
School performance
Indigenous family support network
Neighborhood characteristics

23. Builds protective factors across the social ecology
MST:
Addresses risk factors across the social ecology (comprehensive services)
Builds protective factors across the social ecology
Accomplishes such on an individualized basis

24. 2. MST SERVICES HAVE HIGH ECOLOGICAL VALIDITY AND ARE INTENSIVE
Home-Based Model of Service Delivery:
Services provided in home, school, and community settings (where problems occur)
Overcomes most barriers to service access
Increases validity of assessment data
Increases validity of outcome data
Helps engage family in treatment
Enhances treatment generalization

25. Low therapist caseloads (4-6 families)
INTENSIVE SERVICES:
Low therapist caseloads (4-6 families)
24 hour/7 day availability of therapist
60 to 100 hours of direct therapist-family contact over 4 months
Therapists work in teams with significant clinical support

26. 3. OVERVIEW OF MST QUALITY ASSURANCE SYSTEM
System is predicated on linkage between therapist fidelity to MST treatment protocols and child/family outcomes
Such a linkage is supported by 6 published studies

27. MST QUALITY ASSURANCE SYSTEM
To Promote Treatment Fidelity, Achieve Outcomes, and Address Barriers to Outcomes
Specified treatment protocol ( Henggeler et al., 1998, Guilford Press)
Specified supervisory protocol (Henggeler & Schoenwald, 1998)
Specified consultation protocol (Schoenwald, 1998)
Ongoing consultation to address organizational barriers to program success

28. Youth/ Family Supervisor Therapist MST Consultants/ MST Institute
MST QUALITY ASSURANCE SYSTEM
Organizational Context
Manualized
Manualized
Youth/
Family
Supervisor
Therapist
Supervisory
Adherence
Measure
Therapist
Adherence
Measure
Manualized
Manualized
MST
Consultants/
MST Institute
Internet communication
Person to Person communication

29. MST QUALITY ASSURANCE SYSTEM
On site 5-day orientation training
Quarterly booster training
Clinicians work within MST teams for peer support
On site clinical supervision from MST-trained supervisor
Weekly consultation with MST expert via conference call
Standardized adherence ratings from caregiver via internet system <
Expert coding of audiotaped treatment sessions for adherence (research studies only)

30. Youth/ Family Supervisor Therapist MST Consultants/ MST Institute
MST QUALITY ASSURANCE SYSTEM
Organizational Context
Manualized
Manualized
Youth/
Family
Supervisor
Therapist
Supervisory
Adherence
Measure
Therapist
Adherence
Measure
Manualized
Manualized
MST
Consultants/
MST Institute
Internet communication
Person to Person communication

31. 4. INTERVENTION STRATEGIES USED WITHIN MST
MST Programs Rely on Evidence-Based Interventions:
Behavior therapy
Cognitive behavior therapy
Pragmatic family therapies
Pharmacological interventions (e.g., ADHD)
Community Reinforcement Approach (Budney & Higgins)

32. BUT, Evidence-Based Interventions Are Used Within:
Social ecological conceptual model
Program commitment to remove barriers to service access
Intensive quality assurance
View that caregivers are key to long-term outcomes
Program philosophy that emphasizes provider accountability for outcomes

33. 5. CAREGIVERS ARE VIEWED AS THE KEY TO LONG-TERM OUTCOMES
Hence:
Most clinical resources devoted to developing capacity of caregiver to achieve goals
Significant clinician attention devoted to delineating and overcoming barriers to effective parenting (e.g., caregiver mental health problems, substance abuse, stress)
Focus on family versus youth

34. 6. MST PROGRAMS ARE ACCOUNTABLE FOR ENGAGEMENT AND OUTCOMES
High Accountability Requires Access to Resources:
High salaries
Low caseloads
Strong clinical support
Strong organizational support
Sharing in program success (i.e., reducing placements)
Opportunity to enhance competencies when success rates are low

35. SCIENCE TO PRACTICE: TRANSPORT OF MST TO COMMUNITY SETTINGS
MST Services – licensed through the Medical University of South Carolina – supports MST program development and provides or supports ongoing training and quality assurance worldwide
301 licensed MST programs in 30 states and 8 nations
Statewide initiatives in Connecticut, Hawaii, Ohio, and South Carolina. Nationwide initiatives in Norway and Denmark
MST programs serve 10,000 serious juvenile offenders annually, 3% of the eligible population

36. MAJOR CHALLENGES TO DISSEMINATION
Funding structures often favor incarceration and residential treatment over community-based services
Clinical services differ significantly from the status quo (e.g., home- and family-based; 24/7 availability of therapists)
Training and quality assurance standards emphasize treatment fidelity and provider accountability, which contrast with existing practices and are often not desired
Perhaps the key research and implementation issue is determining what promotes the effectiveness of dissemination sites, which have varying outcomes

37. POLICY IMPLICATIONS
1. Shift Funding from Ineffective Institution-Based Services to Intensive and Effective Community-Based Services
70% of current service dollars spent on out-of-home placements
Savings can fund:
higher salaries for effective clinicians
prevention programs
early intervention programs

38. Policy Implications - continued 2
Policy Implications - continued 2. Change training and clinical practice
Currently:
Minimal outcome accountability
“Train and hope” approach to technology transfer dominates
Degrees are licenses to practice as one desires until retirement
Change to Performance Contracts to Promote:
Accountability
Outcomes
Use of evidence-based practices

39. QUESTIONS OR MORE INFORMATION
Research Related: Scott W. Henggeler
Publication Requests: <musc.edu/fsrc>
Dissemination/Site Development:
Marshall Swenson,